Background

Of all the elements that interact in the day-to-day operations of a hospital, the administrative and organizational aspects are among the most important in ensuring that disaster prevention and mitigation measures are adopted before a disaster strikes, so that the hospital can continue to function after an earthquake or other catastrophic event.

Administrative and organizational vulnerability to emergencies and disasters can be analyzed at two different levels. The macro level involves studying the resolution capacity of health facilities, which is based on currently popular concepts of health services modernization and decentralization. This type of analysis is ambitious: its final objective is the implementation of a total quality management policy for health services (see box 4.1). Continually improving the quality of a health facility’s services automatically brings about improvements in the structural, nonstructural, and administrative and organizational conditions of day-to-day operations, leading to a hospital that performs more effectively, as a whole, in the event of an emergency or disaster. However, such an analysis lies beyond the scope of this book.

This chapter addresses the micro-level, which normally focuses only on those aspects relevant to a particular health establishment. However, it is possible to draw on the information available from several health facilities, to carry out a micro-level analysis of the administrative and organizational vulnerability of a fairly typical hospital. This includes those operational aspects that might have a negative impact on its ability to provide its services both in normal and in external or internal emergency conditions, as we will see in greater detail below. In order to do this, it is necessary to examine the activities carried out in the different departments of a hospital, their interactions, the availability of basic public services, and the modifications required in the event of an emergency.

Similarly, we will perform a critical review of a typical hospital emergency plan, seen as another administrative and organizational tool, in order to identify its possible weaknesses and underscore the useful components related to guaranteeing the functionality of existing services. It is important to stress that a hospital emergency plan, no matter how well crafted, will be useless if the building suffers serious damage to its physical infrastructure. Accordingly, this analysis is based on the assumption that structural and nonstructural deficiencies have been corrected or, if this has not yet been accomplished, that they have at least been identified and the emergency plan has taken them into account.

The Continual Quality Improvement Process (CQIP) is a new managerial approach that is being introduced in health care programs worldwide.* A CQIP is based on the assumption that many organizational problems result from inadequate systems and processes, rather than individual mistakes. A CQIP encourages the staff at all levels to work as a team, take advantage of collective experience and skills, analyze processes and systems, use available information to identify the nature and magnitude of each problem, and design and execute actions that improve services. Quality is continuously reviewed and incorporated into the working process. Improvements in all functions are carried out gradually and continuously (proactively), and staff members are encouraged to take the initiative, quashing the myth that quality is expensive.

The state of California, in the United States, has very precise terms of reference for contracting preliminary studies and the implementation of CQIP in health services. These include reviewing processes in clinical and non-clinical services, including emergency care, family planning and health education. A CQIP must be steered by a committee that includes the medical director of each health facility, doctors and health personnel, administrators and technicians. CQIP studies must reflect the needs of the population based on age and disease categories.

* Department of Health Services of the State of California. Quality improvement system, 1992.

In the event of a disaster, a hospital must be able to continue caring for its inpatients while treating victims of the event, safeguarding all the while the lives and health of its personnel. For this to happen, the staff must be deployed effectively and know exactly how to respond to such a situation. The building and its equipment, supplies and lifelines must remain operational. Most hospital authorities recognize this fact, which is why they have established formal disaster mitigation plans.

However, most of these plans fail to provide administrative and organizational alternatives in the event of severe damage to the facilities. The issue has received little attention. This is worrisome, particularly in the many locations throughout the Americas where the population only has ready access to one hospital that, if rendered inoperative, could lead to a severe health crisis.

A systematic approach, which takes into account the fluid movement of staff, equipment and supplies in a safe environment during normal operations, is vital if an effective response to disasters is to be in place. This underscores the critical nature and interdependence of the various processes, buildings, and equipment. Deficiencies in any of these areas can plunge a hospital into a crisis.

i) Processes: They mostly have to do with the movements of people, equipment and supplies. They also include routine administrative processes such as hiring, acquisitions, human resource management, and the flow of patients through the various clinical and support service areas of the hospital.

ii) Buildings: Experience has shown that the design and construction of hospital buildings, as well as their future expansion and remodeling, their everyday operations and maintenance, must be safety-oriented to protect certain critical hospital operations such as emergency care, diagnosis and treatment, surgery, pharmaceutical supplies and food storage, sterilization, patient registration, reservations, or any other areas the institution considers a high priority.

In hospital design, emphasis must be placed on the optimal use of space and the configuration of the services provided, so that the different departments and activities can mesh together with the greatest possible efficiency and the lowest vulnerability. Many facilities have suffered a functional collapse as a result of simple omissions during their design, which could have been easily corrected or addressed at a marginal cost during construction or retrofitting.

iii) Equipment: Regular inspections and the proper maintenance can ensure that key and often costly hospital equipment can remain in good working order.

As discussed earlier, it is the duty of the authorities to assess the hospital’s vulnerability to natural phenomena and obtain precise estimates of existing risk levels. Once the analysis is complete, the information gathered should be used to determine what level of risk is acceptable. In the case of administrative and organizational vulnerability, the analysis can start with a visual inspection of the facilities and the drafting of a preliminary assessment report identifying key areas that demand attention, alongside a study of administrative procedures, their critical points, and their flexibility in emergency situations.